Cost-effectiveness analysis of drugs for osteoporosis treatment in elderly Japanese women at high risk of fragility fractures: comparison of denosumab and weekly alendronate

Economic evaluation of four treatment strategies for postmenopausal patients with osteoporosis and a recent fracture in mainland China: a cost-effectiveness analysis

Postmenopausal patients with osteoporosis who have a recent fracture are at very high risk of fracture, and this study finds that stratified treatment based on fracture risk would be a cost-effective treatment option for this population.

PURPOSE

To evaluate the cost-effectiveness of four anti-osteoporosis medications (denosumab, zoledronate, teriparatide, and alendronate) for postmenopausal osteoporotic women in mainland China, using a stratified treatment strategy recommended by the American Association of Clinical Endocrinologists and the American College of Endocrinology (AACE/ACE).

METHODS

A microsimulation Markov model was used to compare the cost-effectiveness of the four treatments in postmenopausal osteoporotic patients of different ages (65, 70, 75, and 80 years), with a recent fracture from the Chinese healthcare perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER), which represent the incremental cost per quality-adjusted life-year (QALY) obtained. One-way deterministic sensitivity analysis (DSA) and probabilistic sensitivity analysis (PSA) were performed to assess the robustness of model findings.

RESULTS

Alendronate was dominated by denosumab-to-alendronate and zoledronate at all ages examined, indicating that the costs of the two drugs were lower, but QALYs was greater. However, teriparatide-to-alendronate yielded an ICER of $76,432.07/ QALY, compared with alendronate at age 65, which exceeded the pre-determined willingness-to-pay threshold of $37,653/ QALY. The results were similar at other ages. The DSA showed that the most sensitive parameters were drug efficacy for vertebral and wrist fractures, the relative risk of vertebral fractures, and the persistence of the drugs. The PSA showed that zoledronate had a 100% probability of being the most cost-effective treatment, with a willingness-to-pay threshold of $37,653/ QALY.

CONCLUSION

Stratified treatment based on very high fracture risk is more cost-effective than conventional pills in mainland China. Among the stratified treatments, zoledronate is the optimal option.

Cost Effectiveness of Denosumab for Secondary Prevention of Osteoporotic Fractures Among Postmenopausal Women in China: An Individual-Level Simulation Analysis

OBJECTIVE

This study evaluated the cost effectiveness of denosumab versus alendronate for secondary prevention of osteoporotic fractures among post-menopausal women in China.

METHODS

A validated individual-level simulation model of osteoporotic fractures in the Chinese setting was adapted. Allowing both treatment discontinuation and waning effects, the analysis aimed to evaluate the incremental cost-effectiveness ratio of denosumab compared to alendronate by simulating a cohort of previously fractured individuals over the residual lifetime from the healthcare system perspective. Hip, vertebral, and wrist/humeral fractures were tracked along with the associated medical costs and quality-adjusted life-years. Age-related health state utility values, health state utility values of fractures, costs, fracture incidence, and mortality risks for Chinese were used whenever available. Comparative effectiveness data were obtained from a published network meta-analysis. One-way and probabilistic sensitivity analyses were conducted.

RESULTS

In the base case, denosumab was dominated by alendronate with incremental costs of CN¥2743 (US$425) and incremental health outcomes of - 0.20 quality-adjusted life-years at its current price in mainland China. It remained dominated in all one-way sensitivity analysis robustness checks. However, denosumab was cost effective if both drugs did not carry any waning effects. In the probabilistic sensitivity analysis, denosumab remained dominated in all replications.

CONCLUSIONS

Denosumab is not cost effective for preventing secondary fractures among overall postmenopausal women in China. It is advisable to identify alternative denosumab regimens for high-risk subgroups among previously fractured postmenopausal women.

Cost-effectiveness of Denosumab for the Treatment of Postmenopausal Osteoporosis in Malaysia

From the perspective of Malaysian health care providers, denosumab was cost-effective in the treatment of postmenopausal osteoporosis, with an optimal outcome starting at age 60 years. Our results provide important insights into the value for money of anti-osteoporotic agents that can serve as a reference for other countries with comparable epidemiological data.

INTRODUCTION

The study aimed to compare the cost-effectiveness of denosumab with alendronate and no treatment in the management of postmenopausal osteoporosis among the Malaysian population.

METHODS

A well-validated Markov model was used to estimate the cost-effectiveness of denosumab in a hypothetical cohort of postmenopausal osteoporotic women between 50 and 80 years old who had no history of fractures. A 10-year time horizon from the perspective of Malaysian health care providers was used in this analysis. The model parameters, including transition probabilities and costs, were based on Malaysian sources. Treatment efficacy data were obtained from a network meta-analysis. The study outcomes were presented as incremental cost per quality-adjusted life-year (QALY) gained. Sensitivity analyses were performed to ensure the robustness of the results. A cost-effectiveness threshold was set at MYR 21,438 (USD 5175) per QALY.

RESULTS

Denosumab was found to be a cost-effective option for postmenopausal osteoporotic women aged 60 and older. The incremental cost-effectiveness ratios (ICERs) for denosumab versus alendronate ranged from MYR 16,955 (USD 4093) per QALY at age 60 to MYR 4380 (USD 1057) per QALY at age 80. The cost-effectiveness of denosumab improved monotonically with increasing age. Denosumab was 72.8-92.7% likely to be cost-effective at the cost-effectiveness threshold. Sensitivity analyses demonstrated that the results were robust across all parameter variations, with the annual cost of denosumab being the most sensitive.

CONCLUSIONS

From the perspective of the Malaysian health care provider, denosumab appears to be a cost-effective treatment choice for postmenopausal osteoporotic women over 60 years of age.

Cost-effectiveness analyses of denosumab for osteoporosis: a systematic review

This paper systematically reviewed and assessed all retrievable pharmacoeconomic studies on denosumab for the treatment of osteoporosis. Denosumab was more cost-effective in patients with older age, prior fracture experience, lower BMD T-scores, and more risk factors. ESCEO-IOF guidelines were more applicable to improve the quality of pharmacoeconomic studies in osteoporosis.

INTRODUCTION

There are many pharmacoeconomic studies on denosumab for osteoporosis. However, the corresponding reviews are outdated or incomplete and need to be updated and refined. This article aims to systematically review and evaluate all retrievable pharmacoeconomic studies of denosumab for osteoporosis.

METHODS

A systematic literature search was performed utilizing PubMed, EMBASE(Ovid), Proquest(EconLit), Chongqing VIP, WanFang Database, and Chinese National Knowledge Infrastructure to identify full-text articles published before September 2021. The quality of full-text articles was evaluated by the Consolidated Health Economic Evaluation Reporting Standards(CHEERS) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases International Osteoporosis Foundation guideline(ESCEO-IOF).

RESULTS

In total, 21 full-text articles were eligible for inclusion. Denosumab for postmenopausal osteoporosis was not dominant compared to zoledronate and teriparatide. However, denosumab was dominant compared with strontium ranelate, raloxifene, and ibandronate in patients over 65 years. The probabilities of denosumab being cost-effective or dominant were more than 85% compared with no treatment and risedronate in patients aged over 70 years. Compared to alendronate, the highest rate of denosumab dominance occurred in patients aged 65 to 75 years, at about 65%. Most of the articles had higher CHEERS scores than ESCEO-IOF scores (converted into percentages).

CONCLUSIONS

The cost-effectiveness of denosumab for the treatment of osteoporosis was influenced by multiple factors. Generally, denosumab was more cost-effective in patients with older age, prior fracture experience, lower BMD T-scores, and more risk factors. ESCEO-IOF guidelines were more applicable to improve the transparency, generalization, and quality of pharmacoeconomic studies in osteoporosis.

Medical expenditures for fragility hip fracture in Japan: a study using the nationwide health insurance claims database

Using the nationwide health insurance claims database in Japan, we estimated total annual medical expenditures for fragility hip fracture across the population at 329.2 billion yen (2.99 billion US dollars). Long-term care expenditures were not included. Fragility hip fracture imposes a considerable health economic burden on society in Japan.

PURPOSE

Fragility hip fracture imposes a substantial health economic burden on society globally. We aimed to estimate medical expenditures for fragility hip fracture using the nationwide health insurance claims database in Japan.

METHODS

We included adults aged 60 and over without prior hip fracture who were admitted for fragility hip fracture (i.e., femoral neck or extracapsular) between October 2014 and October 2015 (13 months). Fragility hip fracture was identified through newly assigned disease codes for fracture and procedure codes associated with the fracture. As a proxy for medical expenditures per patient, incremental payments were calculated (i.e., the difference between the total payments 6 months before and after fragility hip fracture). The total payments included health insurance reimbursements and copayments for inpatient and outpatient services. Long-term care expenditures were not included in this study.

RESULTS

We identified 142,361 individuals (28,868 male and 113,493 female) with fragility hip fracture. Mean medical expenditures for fragility hip fracture per patient were 2,550,000 yen (¥) (23,180 US dollars [$]; ¥110 = $1) in male and ¥2,494,000 ($22,670) in female patients, respectively. Total annual medical expenditures for fragility hip fracture across the population were 329.2 billion yen (2.99 billion US dollars): 67.96 billion yen (620 million US dollars) in male and 261.24 billion yen (2.37 billion US dollars) in female patients, respectively.

CONCLUSION

This is the first study to estimate medical expenditures for hip fracture using the nationwide health insurance claims database, which represents almost all health insurance claims in Japan. Fragility hip fracture inflicts a considerable health economic burden on society in Japan.

Short-term efficacy and safety of zoledronate acid or denosumab in Japanese patients with postmenopausal osteoporosis

INTRODUCTION

We aimed to compare the efficacy after switching from either bisphosphonates (BPs) or non-BPs (NBPs) to combination therapies of denosumab (DMAb) or zoledronic acid (Zol) with eldecalcitol (ELD) in bone mineral density (BMD) and bone metabolism and investigate the prognostic and risk factors of side effects of this therapy.

MATERIALS AND METHODS

One-hundred forty-eight patients with postmenopausal osteoporosis were recruited; their therapy was switched from BPs or NBPs to Zol or DMAb plus ELD (BP-Zol: 43, NBP-Zol: 32, BP-DMAb: 35, and NBP-DMAb: 38). Longitudinal changes in bone metabolic markers (P1NP and TRACP-5b) and BMD were evaluated.

RESULTS

In the BP-Zol group, P1NP did not change after 6 months and increased by 38.9% after 12 months. TRACP-5b decreased 15.8% after 6 months, but came back to baseline values 12 months after administration. In the rest of the groups, the bone metabolic markers remained suppressed after 6 and 12 months. Compared with baseline, all groups showed increase in BMD after 6 and 12 months. Bone metabolic markers at baseline were correlated with %change in lumbar spine BMD from baseline to 12 months. P1NP and 25-hydroxy vitamin D levels at baseline were identified as potential predictors of development of acute-phase reactions.

CONCLUSIONS

The combination therapy of Zol or DMAb and ELD may increase BMD at 12 months after the first administration in Japanese patients with postmenopausal osteoporosis, regardless of BPs pretreatment. Bone metabolic markers at baseline may be useful predictors for reaction to the therapy and side effects caused by these combination therapies in postmenopausal osteoporosis.

Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region

Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care.

PURPOSE

Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development.

METHODS

We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards.

RESULTS

Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines.

CONCLUSION

The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.

The miR-187 induced bone reconstruction and healing in a mouse model of osteoporosis, and accelerated osteoblastic differentiation of human multipotent stromal cells by targeting BARX2

BACKGROUND

Multiple microRNAs (miRNAs) have been proven to regulate osteogenic differentiation by affecting the Runx2 signaling pathway. The intervention of miRNA can delay the progress of osteoporosis (OP) and induce fracture repair by affecting bone regeneration. However, the function and mechanism of miR-187 in osteoporotic fractures are still unknown.

METHODS

We first established the OP mouse model. Next, the BMD value was certified by iDXA. The miR-187 level in the OP mice and serum of OP patients was identified through qRT-PCR. Bone repair and bone healing were assessed through toluidine blue staining and X-ray, and BARX2 expression was also confirmed. Osteogenesis-related proteins, ALP activity, and the matrix mineralization state were evaluated by western blot, ALP staining, and Alizarin Red staining in hMSCs after transfection with miR-187 mimics, miR-187 inhibitor, or human BarH-like homeobox 2 (BARX2) siRNA. Moreover, the interplay between miR-187 and BARX2 was identified through the dual-luciferase reporter.

RESULTS

The BMD value was notably reduced in the OP mice, and miR-187 was markedly downregulated in the OP mice and serum of OP patients. Meanwhile, we proved that miR-187 induced bone reconstruction and healing, and downregulated BARX2 in the OP mouse model. We also proved that BARX2 was a direct target of miR-187, and could be significantly downregulated by miR-187. Furthermore, miR-187 induced osteogenic differentiation of hMSCs by targeting BARX2.

CONCLUSIONS

The miR-187 might have a significant therapeutic effect in osteoporotic fractures. miR-187 accelerated osteogenic differentiation of hMSCs by directly regulating BARX2.

An Updated Systematic Review of Cost-Effectiveness Analyses of Drugs for Osteoporosis

BACKGROUND

Considering the heavy economic burden of osteoporotic fractures, the limits of healthcare resources, and the recent availability of new anti-osteoporosis drugs, there is continuing interest in economic evaluation studies of osteoporosis management strategies.

OBJECTIVES

This study aims to (1) systematically review recent economic evaluations of drugs for osteoporosis and (2) to apply an osteoporosis-specific guideline to critically appraise them.

METHODS

A literature search was undertaken using PubMed, EMBASE, National Health Service Economic Evaluation database, and the Cost-Effectiveness Analysis Registry to identify original articles containing economic evaluations of anti-osteoporosis drugs, published between 1 July, 2013 and 31 December, 2019. A recent European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases-International Osteoporosis Foundation (ESCEO-IOF) guideline for the conduct and reporting of economic evaluations in osteoporosis was used to assess the quality of included articles.

RESULTS

The database search retrieved 3860 records, of which 27 studies fulfilled the inclusion criteria. These studies were conducted in 15 countries; 12 active drugs were assessed, including various traditional pharmacological treatments such as bisphosphonates, raloxifene, strontium ranelate, denosumab, and teriparatide, and new agents such as abaloparatide, romosozumab, and gastro-resistant risedronate. Eight out of 12 studies that compared traditional oral bisphosphonates to other active interventions (denosumab, zoledronic acid, gastro-resistant risedronate, and teriparatide) suggested that the other active agents were generally cost-effective or dominant. Additionally, the cost-effectiveness of sequential therapy has recently been assessed and indications are that it can lead to extra health benefits (larger gains in quality-adjusted life-year). The key drivers of cost effectiveness included baseline fracture risk, drug effect on the risk of fractures, drug cost, and medication adherence/persistence. The current average score for quality assessment was 17 out of 25 (range 2-15); room for improvement was observed for most studies, which could potentially be explained by the fact that most studies were published prior to the osteoporosis-specific guideline. Greater adherence to guideline recommendations was expected for future studies. The quality of reporting was also suboptimal, especially with regard to treatment side effects, treatment effect after discontinuation, and medication adherence.

CONCLUSIONS

This updated review provides an overview of recently published cost-effectiveness analyses. In comparison with a previous review, recent economic evaluations of anti-osteoporosis drugs were conducted in more countries and included more active drugs and sequential therapy as interventions/comparators. The updated economic evidence could help decision makers prioritize health interventions and the unmet/unreported quality issues indicated by the osteoporosis-specific guideline could be useful in improving the transparency, quality, and comparability of future economic evaluations in osteoporosis.

Systematic evidence of health economic evaluation of drugs for postmenopausal osteoporosis: A quality appraisal

This paper systematically and critically reviewed all published economic evaluations of drugs for the treatment of postmenopausal osteoporosis. A systematic search was conducted using relevant databases for economic evaluations to include all relevant English articles published between January 2008 to January 2020. After extracting the key study characteristics, methods and outcomes, we evaluated each article using the Quality of Health Economic Studies (QHES) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) instruments. A total of 49 studies met the inclusion criteria. Majority of studies were funded by the industry and reported favorable cost-effectiveness. Based on the QHES total scores, studies (n = 35) were found to be industry-funded with higher QHES mean 82.44 ± 8.69 as compared with nonindustry funding studies (n = 11) with mean 72.22 ± 17.67. The overall mean QHES scores were found to be higher 79.06 ± 11.84, representing high quality (75–100) compared to CHEERS scores (%) 75.03 ± 11.21. The statistical pairwise comparison between CHEERS mean (75.03 ± 11.21) and QHES mean (79.06 ± 11.84) were not statistically significant (P = 0.10) whereas, QHES score showed higher means as compared to CHEERS. This study suggests the overall quality of the published literatures was relatively few high-quality health economic evaluation demonstrating the cost-effectiveness of drugs for postmenopausal osteoporosis, and the majority of the literature highlights that methodological shortcoming.

Gender- and Age-Related Changes in Trunk Muscle Composition Using Chemical Shift Encoding-Based Water⁻Fat MRI

Ageing, sarcopenia, and malnutrition are associated with quantitative and qualitative changes of body composition. There are several imaging modalities, including magnetic resonance imaging (MRI), for the assessment of trunk muscle tissue composition. In this study, we investigated the gender- and age-related changes in trunk muscle composition using chemical shift encoding-based water–fat MRI. A total of 79 healthy volunteers (26 men: 38.9 ± 10.4 years; 53 women: 39.5 ± 15.0 years) underwent 3T axial MRI using a six-echo multi-echo 3D spoiled gradient echo sequence, allowing for the calculation of the proton density fat fraction (PDFF) in the trunk muscles. PDFF of the abdominal, psoas, and erector spinae muscles were determined. We detected significant positive correlations for abdominal muscle PDFF with age (r = 0.638, p = 0.0001) in men, and for abdominal muscle PDFF (r = 0.709, p = 0.0001) and erector spinae muscle PDFF (r = 0.674, p = 0.0001) with age in women. After adjustment for body mass index (BMI), only the correlation of age and abdominal muscle PDFF in women remained significant (r = 0.631, p = 0.0001). The findings of this study suggest that an increasing fat deposition in muscle is driven primarily by age, rather than BMI, in women. These results further support that PDFF can be considered a valid imaging biomarker of trunk muscle composition.